Anaesthetic Room Research Articles

Assessment of the carbon footprint of total hip arthroplasty and opportunities for emission reduction in a UK hospital setting.

This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices. Using a life-cycle assessment approach, we conducted a prospective study on ten cemented and ten hybrid THA cases, evaluating carbon emissions from anaesthetic room to recovery. Scope 1 and scope 2 emissions were considered, focusing on direct emissions and energy consumption. Data included detailed assessments of consumables, waste generation, and energy use during surgeries. The carbon footprint of an uncemented THA was estimated at 100.02 kg CO2e, with a marginal increase to 104.89 kg CO2e for hybrid THA. Key contributors were consumables in the operating theatre (21%), waste generation (22%), and scope 2 emissions (38%). The study identified opportunities for reducing emissions, including instrument rationalization, transitioning to LED lighting, and improving waste-recycling practices. This study sheds light on the substantial carbon footprint associated with THA. Actionable strategies for reducing emissions were identified, emphasizing the need for sustainable practices in orthopaedic surgery. The findings prompt a critical discussion on the environmental impact of single-use versus reusable items in the operating theatre, challenging traditional norms to make more environmentally responsible choices.

WP5.3 - Rejuvenating the golden patient protocol in a tertiary centre general surgical emergency theatre

Abstract Aims Poor patient flow and complex sub-specialty decision making discussions lengthened time to operation of lower priority operations e.g. appendicectomy/abscesses. By prioritising start times and registrar patient selection for low complexity cases/day case discharge, we rejuvenated the golden patient protocol (GPP) and assessed the implementation and impact of a novel GPP in a tertiary centre emergency list on surgical wait times and overall theatre flow. Methods The GPP was agreed between surgical/anaesthetic night registrars and theatre staff which took into consideration the urgency of the surgery, fitness of patient and anaesthetic/technical difficulties. Eligible patients were identified prior to 08:00 and scheduled as the first case of the day to be huddled and sent for by 08:30. Two cycles were conducted, one month before and after GPP introduction, using the trust theatre management system (TMIS). Results Time series analysis was conducted for patient sent-for, anaesthetic room entry, and procedure start times during both cycles. Results indicated a median decrease of 11-minutes in patient sent-for time (Cycle 1: 08:56, Cycle 2: 08:45) and a 12-minute reduction in median procedure start time (Cycle 1: 09:42, Cycle 2: 09:30). The proportion of low complexity cases performed first-on-list also increased by 22.5% (Cycle 1: 35.5%, Cycle 2: 58.0%). Conclusions This analysis demonstrates a positive change by starting theatre faster with lower complexity cases, developing surgical registrar independence, improving time to treatment without complex discussions delaying first send.

Anesthesia and Operating Room Waste Management

Introduction Operating rooms (ORs) are associated with high waste generation that contribute significantly to the overall hospital waste production, costs, and environmental impact. Hence, this study sought to explore the impact of the revision of single-use surgical packs in waste reduction and hospital cost savings. Methods A systematic review with meta-analysis was conducted to assess waste reduction strategies in operating rooms. A search was conducted on databases to evaluate the impacts of interventions on anesthesia waste reduction and cost savings. The search was limited to studies conducted between 2014 and 2024. Results The findings of the systematic review indicate that the revision of single-use surgical packs was associated with significant reductions in OR and anesthesia waste production and hospital costs. Conclusion The findings show that waste reduction initiatives could be effective in enhancing the sustainability of surgical procedures. The study underscores the role of simple but sustainable practices in addressing persistent environmental and financial challenges in the healthcare sector.

578 Optimising Emergency Theatre Efficiency with the Use of a Pre-Anaesthetic Holding Bay, a Quality Improvement Project

Abstract Aim An efficient emergency theatre depends on the coordination of multiple surgical specialties, anaesthetists, and theatre staff. The serial nature of an operating list leads to downtime between cases. We sought to reduce delays between emergency cases by implementing a pre-anaesthetic holding bay. Method Anonymised data was collected from a prospectively maintained mandatory database of theatre activity. Exclusion criteria were non-surgical procedures, first case, out-of-hours procedures, and critical care admissions. Suitability was determined from a period pre-implementation and a pre-defined trial period to ensure safe rollout. Pre-, trial, and post-implementation were compared. Results 349 emergency procedures were performed in three months post-implementation. After exclusion criteria 110 were suitable for pre-anaesthetic holding bay use, and in 35 (31.8%) it was utilised. Most cases were general surgery (61%), vascular surgery (15%), and gynaecology (12%). Holding bay use decreased time without a patient in the anaesthetic room from 50 to 5 minutes (p<.001) and the time between procedures from 86 to 43 minutes (p<.001). There was no difference in anaesthetic time between the groups (36 vs 38 minutes, p=.40). Over the three months 40 more in-hours cases were completed in 48 days with no difference in procedures across the periods. Conclusions Pre-anaesthetic holding bay use reduced theatre downtime by 90%, allowing more procedures to be performed in-hours. All specialties engaged with the holding bay but to varying extent, and ensuring investment from surgeons, anaesthetists, and theatre staff is essential. This intervention, implemented with no extra resources, has increased efficiency and improved safety in the emergency theatre list.

The provision of a trauma bed in theatre recovery and its impact on trauma theatre efficiency: experience from a high-volume trauma unit.

Inefficiencies in the trauma setting are well known and have been further exacerbated by the COVID-19 pandemic among other factors, resulting in national guidance to aid improvements in resource utilisation. This study introduced a novel surgeon-led intervention, a trauma bed in recovery, with the aim of improving trauma theatre efficiency. This quality improvement project was conducted using a Plan Do Study Act (PDSA) methodology and comprised multiple cycles to assess theatre performance. A multidisciplinary team (MDT) approach with relevant stakeholder input enabled intervention implementation, aimed at facilitating 'golden patient' arrival in the anaesthetic room as early as possible. The primary outcome was the time at which the first patient entered the anaesthetic room, and the secondary outcome was the number of cases performed each day. The study period was 1 year and encompassed three PDSA cycles. The intervention achieved its primary outcome by PDSA cycle 1 and its secondary outcome by PDSA cycle 2, demonstrating statistically significantly improved results (p < 0.001). A subanalysis assessed the specific impact of the intervention, and demonstrated a significant improvement in both outcomes when the intervention was used as intended (p < 0.0005). A ringfenced trauma bed significantly improved theatre start times and thereby theatre efficiency. This is a simple, pragmatic intervention that benefitted the MDT trauma team while also demonstrating a sustained impact. Given that National Health Service efficiency is at the forefront of national healthcare discourse, we recommend that this intervention is implemented in other trauma units to help provide a solution to this longstanding issue.

COMPARISON OF BUPIVACAINE ALONE AND BUPIVACAINE PLUS LIDOCAINE IN SUPRACLAVICULAR BLOCK UNDER ULTRASOUND GUIDANCE

This study aimed to compare the effectiveness of bupivacaine alone versus bupivacaine combined with lidocaine in patients undergoing ultrasound-guided supraclavicular block. Specifically, the study focused on the onset time and duration of the block effect. The study was designed as a retrospective study in the anesthesia room of the operation theater of Sheikh Zayed Hospital, Lahore, from 2nd November 2021 to 1st May 2022. A total of 200 patients who met the inclusion criteria were included in the study. Prior to the intervention, patients were given midazolam (2mg) to help alleviate anxiety. The participants were then divided into two groups, with 100 patients in each group. Group A received bupivacaine 20 ml (5 mg/ml), while Group B received bupivacaine 10 ml (5 mg/ml) in combination with lidocaine 10 ml (20 mg/ml). The onset and block effect times were recorded in a Performa and subjected to statistical analysis. The results of the study showed that the mean block onset time in Group A (bupivacaine alone) was 9.4±1.34 minutes, while in Group B (bupivacaine plus lidocaine), the mean block onset time was 5.4±0.83 minutes (p=0.000). A comparison of the mean block effect time revealed that in Group A, the mean block effect time was 4±1.34 minutes, while in Group B, the mean block effect time was 6±0.83 minutes. This difference was found to be statistically significant (p=0.000). In conclusion, the study demonstrated that the combination of bupivacaine plus lidocaine was significantly associated with a shorter block onset time and a longer block effect time compared to bupivacaine alone.

Organisation of UK hospitals and anaesthetic departments in the treatment of peri‐operative cardiac arrest: an analysis from the 7th National Audit Project (NAP7) local co‐ordinator baseline survey

SummaryWe report the results of the Royal College of Anaesthetists' 7th National Audit Project organisational baseline survey sent to every NHS anaesthetic department in the UK to assess preparedness for treating peri‐operative cardiac arrest. We received 199 responses from 277 UK anaesthetic departments, representing a 72% response rate. Adult and paediatric anaesthetic care was provided by 188 (95%) and 165 (84%) hospitals, respectively. There was no paediatric intensive care unit on‐site in 144 (87%) hospitals caring for children, meaning transfer of critically ill children is required. Remote site anaesthesia is provided in 182 (92%) departments. There was a departmental resuscitation lead in 113 (58%) departments, wellbeing lead in 106 (54%) and departmental staff wellbeing policy in 81 (42%). A defibrillator was present in every operating theatre suite and in all paediatric anaesthesia locations in 193 (99%) and 149 (97%) departments, respectively. Advanced airway equipment was not available in: every theatre suite in 13 (7%) departments; all remote locations in 103 (57%) departments; and all paediatric anaesthesia locations in 23 (15%) departments. Anaesthetic rooms were the default location for induction of anaesthesia in adults and children in 148 (79%) and 121 (79%) departments, respectively. Annual updates in chest compressions and in defibrillation were available in 149 (76%) and 130 (67%) departments, respectively. Following a peri‐operative cardiac arrest, debriefing and peer support programmes were available in 154 (79%) and 57 (29%) departments, respectively. While it is likely many UK hospitals are very well prepared to treat anaesthetic emergencies including cardiac arrest, the survey suggests this is not universal.

1068 Are There Delays to Emergency CEPOD Theatre Times? a Closed-Loop Audit Before and After Having a Dedicated CEPOD Registrar

Abstract Aim To evaluate delays to Emergency Theatre (CEPOD) start times, “knife-to-skin” times, turnover between cases, and whether having a separate Registrar for CEPOD has improved theatre flow. Method This was a closed-loop retrospective audit at Walsall Manor Hospital with data collected using the electronic system, in two 4-week blocks; from 13/06/2022 – 10/07/2022 and then again from 18/07/22 – 14/08/22. 4 days were excluded due to external factor delays which could not be attributed to the theatre team. The target for patients being sent for was 08:40 AM, and arrival was 09:00 AM as per hospital policy. Results 90.4% (47/52) of patients who were the first case of each day were sent for after 08:40 AM. 88.5% (46/52) arrived in the anaesthetic room after 09:00 AM. 94.2% (49/52) had “knife-to-skin” after 09:30 AM and 71.2% (37/52) after 10:00 AM. 36.5% (19/52) had a turnover time of more than 30 mins between cases. There were statistically significant differences between the mean times for the following categories when there was a single on-call Registrar vs when there was a dedicated CEPOD registrar: Time sent for (09:33 vs 09:08, p-value 0.015), Arrival Time (10:00 vs 09:32, p-value 0.010) and turnover time between cases (00:39 vs 00:11, p-value 0.018). Conclusions There are significant delays to CEPOD start times, anaesthetic times, “knife-to-skin times, and turnover times. Having a separate dedicated CEPOD registrar made a difference to the flow of emergency cases.

187 Improving adherence to anaesthetic room preoperative shaving: A surgical site infection quality improvement project

Abstract Introduction The correlation between hair removal and surgical site infection (SSI) remains debated but the limited guidance suggests when hair removal is necessary it should take place in the anaesthetic room. Our local policy is for preoperative hair removal to be performed in the anaesthetic room. We completed a quality improvement project after auditing our practice. Methods Location of preoperative shaving in emergency and trauma theatres were recorded for 7 days. Results were presented to surgical leadership teams and SSI steering groups, and information was disseminated to surgical and anaesthetic teams. Posters specifying the appropriate location of hair removal were created. Results were re-audited after six weeks. Results Pre-intervention, 15 cases required preoperative hair removal. This included 9 general surgery cases, 2 urology, 1 gynaecology and 4 trauma and orthopaedics. Overall, 6/15 (40%) cases were shaved in the anaesthetic room. The rates of hair shaving in the anaesthetic room were 2/9 (22%) general surgery, 1/2 (50%) urology, 1/1 (100%) gynaecology, and 2/4 (50%) trauma. Post-intervention, 9/12 (75%) cases were shaved in the anaesthetic room. This included 7/9 (78%) general surgery, 1/2 (50%) urology, 0/0 gynaecology and 1/1 (100%) trauma and orthopaedics. Conclusion The rate of appropriate preoperative hair shaving in the anaesthetic room increased as a result of initial audit and intervention. Notable change was observed in general surgery in emergency theatres. Future studies should record the rate of surgical site infection, to determine the overall effect this can have on patients and should extend the assessment to elective theatre.

SP9.8 An Audit of Intraoperative Hypothermia Rates in Adults Undergoing Emergency Surgery in a Tertiary General Surgical Unit and Evaluation of the Efficacy of Preoperative and Intraoperative Forced-Air Warming on Achieving Intraoperative Normothermia

Abstract Aims Surgical site infections (SSIs) inflict significant economic burden on the NHS. Preoperative and intraoperative hypothermia are risk factors for SSIs. Evidence shows that maintenance of intraoperative normothermia significantly reduces SSI rates. Perioperative SSI bundles addressing factors including hair removal, antibiotic prophylaxis, skin preparation, drape positioning, and hypothermia are critical to improving SSI rates. We aim to audit rates of intraoperative hypothermia in our surgical caseload and evaluate the efficacy of preoperative and intraoperative forced-air warming through bespoke gowns in achieving intraoperative normothermia. Methods We conducted a retrospective audit of the intraoperative core temperatures of all adult patients undergoing surgical procedures on the emergency theatre list of a general surgery department and who had a temperature at knife-to-skin recorded (n=88). We then ran a prospective trial, outfitting patients listed for surgery (n=15) with forced-air warming gowns. Patients underwent forced-air warming with the gowns for 45 minutes on the surgical ward, throughout anaesthetic induction, and intraoperatively. Patient core temperature was measured at baseline, upon arrival at the anaesthetic room, and at knife-to-skin. Results Baseline audit data showed over 18% of patients were hypothermic at knife-to-skin. Contrastingly, 100% of patients wearing forced-air warming gowns were normothermic at knife-to-skin. The mean core temperature at knife-to-skin was significantly higher in patients wearing warming gowns (p=0.012). Conclusions Forced-air warming gowns are superior to traditional hospital gowns, blankets and surgical access forced-air warming devices in achieving intraoperative normothermia. They are an effective, sustainable, and cost-neutral, ‘all-in-one’ alternative to current perioperative protocol and will reduce SSI rates.

Time-Driven Activity-Based Cost Comparison of Osteoid Osteoma Ablation Techniques

ObjectiveCompare the cost of performing an osteoid osteoma ablation using cone beam CT (CBCT) with overlay fluoroscopic guidance to ablation using conventional CT (CCT) guidance and microwave ablation (MWA) to radiofrequency ablation (RFA). MethodsAn 11-year retrospective study was performed of all patients undergoing osteoid osteoma ablation. Ablation equipment included a Cool tip RFA probe (Covidien, Minneapolis, Minnesota) or a Neuwave PR MWA probe (Ethicon, Rariton, New Jersey). The room times as well as immediate recovery time were recorded for each case. Cost analysis was then performed using time-driven activity-based costing for rate-dependent variables including salaries, equipment depreciation, room time, and certain supplies. Time-independent costs included the disposable interventional radiology supplies and ablation systems. Costs were reported for each service providing care and using conventional cost accounting methods with variable and fixed expenditures. ResultsA total of 91 patients underwent 96 ablation procedures in either CBCT (n = 66) or CCT (n = 30) using either MWA (n = 51) or RFA (n = 45). The anesthesia induction (22.7 ± 8.7 min versus 15.9 ± 7.2 min, P < .001), procedure (64.7 ± 27.5 min versus 47.3 ± 15.3 min; P = .001), and room times (137.7 ± 33.7 min versus 103.9 ± 22.6. min; P < .001) were significantly longer for CBCT procedures. The procedure time did not differ significantly between MWA and RFA (62.1 ± 27.4 min versus 56.1 ± 23.3 min; P = .27). Multiple regression analysis demonstrated lower age (P = .046), CBCT use (P = .001), RFA use (P = .02), and nonsupine patient position (P = .01) significantly increased the total procedural cost. After controlling for these variables, the total cost of CBCT ($5,981.32 ± $523.93 versus $5,378.93 ± $453.12; P = .001) remained higher than CCT and the total cost of RFA ($5,981.32 ± $523.93 versus $5,674.43 ± $549.14; P = .05) approached a higher cost than MWA. ConclusionThe use of CBCT with overlay fluoroscopic guidance for osteoid osteoma ablation resulted in longer in-room times and greater cost when compared with CCT. These cost considerations should be weighed against potential radiation dose advantage of CBCT when choosing an image guidance modality. Younger age, RFA use, and nonsupine patient position additionally contributed to higher costs.

Design of a Nursing Intervention Program to Prevent Adolescents' Perioperative Anxiety

Introduction Adolescents undergoing surgery have expressed a willingness to obtain information about their surgery and to be involved in the decisions about their health care process. Around 80% of adolescents experience anxiety before undergoing surgery. On the basis of the adolescents' shared experiences, areas of possible nursing intervention have been identified to prevent anxiety and the multitude of adverse effects associated with it. The purpose of this study is to present a nursing intervention program to prevent perioperative anxiety in adolescents (3P2A) designed based on the first phase of the complex intervention's framework. Methods The design of this program followed the updated guidance for developing complex interventions issued by the Medical Research Council and the National Institute for Health Research. Five Portuguese nurses, experts in perioperative nursing, and pediatric specialists evaluated and validated the final version of this program. Results The nursing intervention program to prevent perioperative anxiety in adolescents (3P2A) consists of three phases that correspond to the preoperative, intraoperative, and postoperative periods. The first phase includes conducting a preoperative nursing consultation to identify stressors, providing written and verbal information about the surgery, and applying nonpharmacological interventions to reduce anxiety. In the intraoperative period, nonpharmacological interventions are implemented in the anesthetic induction room immediately before the adolescent falls asleep. Finally, the postoperative period comprises a nursing visit to identify postoperative complications and promote the adolescents' well-being. Discussion The program is structured with specific interventions to be implemented in each of the perioperative periods. Because of its flexibility, it may be fully or partially implemented considering the identified needs, priorities, and resources when caring for an adolescent with anxiety during the perioperative period.

Embracing technical improvements in airway management

The surgical on-call team approach a female aged in her mid-30s. She has CT-proven appendicitis and has been kept ‘nil by mouth’ overnight. The consultant takes a seat next to the bed and following introductions and a quick re-assessment, they decide she will need to have it removed surgically. They explain the basics of the procedure, and then pause for a moment. ‘Now, we do have this newer approach whereby we make a few keyholes and remove it with the help of a camera and a couple of ports. It leaves a much smaller scar, causes less pain, and can have you home earlier and back to your normal activities sooner than with an open approach [1]. But I'm just more used to doing it the old-fashioned way, so I am not entirely sure I can offer you this. Also, it takes a fair bit of kit and all sorts of faff. So I guess we'll just consent for an open appendicectomy, shall we?’ Claiming that I found the editorial by Lyons and Harte a refreshing read would be disingenuous [2]. In fact, I imagine many clinicians advocating for the adoption of universal videolaryngoscopy (VL) have grown tired of endless conversations, in academic circles and in anaesthetic rooms, about the merits of direct laryngoscopy (DL) over VL. The anecdotes that ‘one time where DL saved the day’ after a poorly executed hyperangulated VL approach had failed. Or blanket regurgitated statements about the bleeding tonsil where ‘VL is useless anyway’, without anyone even attempting it or being able to produce any robust evidence to support the notion. This editorial makes a tenuous stab in trying to dismantle the now overwhelming evidence favouring VL over DL for most technical and patient-oriented outcomes [3]. At this point, I hope that most readers will agree that such a claim is contentious and does not hold much water at the best of times. We may argue that in 9 out of 10 times, securing the airway will be easy, even though our clinical bedside tests to predict difficulty are notoriously flawed [4]. Adopting a ‘marginal gains’ attitude to improving clinical practice, especially for a risk-laden procedure such as asleep tracheal intubation, with the knowledge that each subsequent attempt after the first one will increase the odds of an adverse outcome, we should be using tools with the best efficacy and safety record [5]. However, there is much work to be done to ensure safe and effective training in VL, with a high-quality hyperangulated VL technique being at the forefront of these efforts. Equally, a universal VL clinical milieu allows the intubator to maintain DL skills, using the best tool to teach DL: a Macintosh-style videolaryngoscope. The fictitious and exaggerated patient interaction I wrote at the beginning, which I hope has never actually taken place, is not unlike our attitudes to the tools and approaches we use in the conduct of anaesthesia. If we were to speak to patients with full candour, a similar conversation would have to take place when defending the routine use of DL today. I hope that as a specialty we can follow in the footsteps of, not only the commonly referred to aviation industry and its attitudes to safety, but also our surgical colleagues.

Evaluation of the Knowledge and Performance of Anesthesia and Operating Room Staff about Fire Sources and Ways to Prevent and Control them in Hospitals Affiliated with Ilam University of Medical Sciences

Evaluation of the Knowledge and Performance of Anesthesia and Operating Room Staff about Fire Sources and Ways to Prevent and Control them in Hospitals Affiliated with Ilam University of Medical Sciences

EGS P07 Management of cutaneous abscesses using the Green Whistle: A Pilot Study

Abstract Background Cutaneous abscesses form a significant volume of emergency general surgery operating throughout the UK. They are most commonly managed with an ‘incision and drainage’ (I&amp;D) procedure which tends to be performed with a general anaesthetic (GA). As expected with the unpredictable nature of emergency general surgery, abscesses booked for I&amp;D under GA are often delayed to accommodate a more urgent procedure or unwell patient. Costs and theatre utilisation of abscesses managed under a general anaesthetic were obtained and analysed. A pilot study was then designed to utilise Methoxyflurane (Penthrox/Green Whistle) as an alternative to general anaesthetic for the management of abscesses. Methods Retrospective data of patients requiring I&amp;D of abscesses under GA between January 2020 and January 2021 was collected. Length of stay (LOS), length of surgery (entry into theatre to out of theatre), time spent in theatre (anaesthetic room and operating theatre) and theatre complex (holding bay, anaesthetic room, operating theatre and recovery) were collected. Financial costs were also obtained. Abscesses were organised into different degrees of complexity: complex, medium and simple. ‘Simple’ abscesses were defined as such if the patient met the following criteria: &amp;gt;18 years, ASA 2 or less, non-perianal or ischiorectal and a surgical time of 10 minutes or less. Following the results, a pilot study was designed and proposed. 20 patients were recruited to this pilot study. Recruitment was performed on admission via the emergency portal (surgical assessment unit). To be eligible for this study, patients would need to meet the following criteria: A patient satisfaction survey was conducted via telephone at a later date. Results 381 patients underwent an I&amp;D under GA. Ratio of M:F was 1.12:1. Majority of abscesses drained were perianal (n=120) and pilonidal (n=81). Majority of patients were ASA 1 or 2. 100 ‘simple’ abscesses were identified. The sum of length of stay (LOS) was 949 days. The sum of surgery time (ST) was 4.6 days. The sum of total theatre time (TT) was 14 days. The sum of time in theatre complex (TC) was 48 days. ‘Simple abscesses’ had a total LOS of 144 days, total ST of 12 hours, total TT of 69 hours and total TC of 12 days. Pilot study: 20 patients had cutaneous abscesses drained between July and September 2021 with Penthrox. M:F ratio was 11:9. 19 patients underwent successful drainage of their abscesses whereas 1 procedure had to be abandoned due to pain. Abscess drainage was performed on the 1st day of presentation in 15 patients. There were no 30-day readmissions noted within this pilot group. 83.3% of respondents to the patient satisfaction survey rated their experience as ‘Very Good’. Costing Overall savings of £4,150 were calculated per patient. Conclusions This study aimed to look into the feasibility of a dedicated abscess pathway for patients meeting specific inclusion criteria. Overall, the results have shown that this is feasible and cost-effective. It reduces length of stay, waiting times and costs. Patients are usually discharged home the same day without any complications. Our data has shown that performing an I&amp;D of an abscess under the Green Whistle pathway costs 30-times as less than the same abscess being managed under a GA in the theatre complex. The pilot study has been ratified at management level and we are currently in the process of stocking Green Whistles in our Surgical Ambulatory Unit and we will shortly begin widespread training and use.

Bridging the realism gap: using ‘low-fidelity’ simulation for high quality training

The Royal College of Anaesthetists recommends use of simulation-based-education (SBE) during the initial 12-week novice placement for new anaesthetic trainees [1]. For many UK anaesthetic departments, the complexity and cost of patient simulators [2] may reduce opportunities for SBE during novice training. However, avoiding the physical fidelity trap [3] and utilising both conceptual and psychological fidelity to good effect might mitigate this issue. As novice trainees are already familiar with the theatre environment from day-to-day clinical practice, the learning outcomes from SBE generally cover rarer emergencies which can still be covered during SBE outside of the theatre environment. We aimed to assess the feasibility of running weekly low physical fidelity SBE across the entire 12-week novice period instead of the smaller number of ad-hoc sessions delivered previously. Our new SBE programme consisted of 30-minute sessions held in the anaesthetic department conference room to minimise impact on stretched theatre capacity and educator availability. To further maximise efficiency, we created a portable simulation set-up using a basic resuscitation manikin on a patient trolley, a disused anaesthetic machine, and a tablet device with a simulated monitor application. This could all be set-up and stored away in under 5 minutes. Our focus on conceptual and psychological fidelity led to the creation of a new scenario bank which identified common issues encountered by new anaesthetic trainees, rather than emergencies rarely encountered by even an experienced anaesthetist. Scenarios needed to be highly plausible and solvable by the novice trainee. Learners were then asked to complete a feedback survey after each session. Feedback from this new simulation programme was very positive and comparable to previous feedback. Across all sessions (n=12) and trainees (n=5), the median Likert scores for perceived relevance, realism, and appropriate challenge were 6/7, 5/7, and 6/7 respectively. All trainees across all sessions indicated they found it useful, enjoyable, and would attend again. In particular, free text responses praised the ability to focus on a single simulated issue without the cognitive overload of the wider theatre environment experienced by new trainees, and the psychological safety benefits of simulation and debriefing in a more relaxed non-theatre setting. This appears to be a feasible and well accepted alternative to our traditional approach, with additional benefits for trainees and reduced impact on service delivery. We now intend to explore use of this approach to deliver increased SBE to the wider anaesthetic and multidisciplinary team. 1. Royal College of Anaesthetists. Simulation Strategy 2018–2023. London: RCoA 2018 2. Fletcher J, Wind A. Cost Considerations in Using Simulations for Medical Training. Military Medicine. 2013;178(10S):37–46. 3. Helyer R, Dickens P. Progress in the utilization of high-fidelity simulation in basic science education. Advances in Physiology Education. 2016;40(2):143–144.

Microplastics in the surgical environment

Atmospheric microplastics (MPs) have been consistently detected within indoor and outdoor air samples. Locations with high human activity are reported to have high MP levels. The aim was to quantify and characterise the MPs present within the surgical environment over a one-week sampling period. MPs were collected in samplers placed around an operating theatre and adjoining anaesthetic room at 12 h intervals. Particles were filtered onto 0.02 µm membranes and analysed using micro-Fourier-transform infrared spectroscopy. The number of MPs identified during the working day sampling period varied, with a mean of 1,924 ± 3,105 MP m−2 day−1 and a range of 0 – 9,258 MP m−2 day−1 observed in the theatre, compared with a mean of 541 ± 969 MP m−2 day−1 and a range of 0 – 3,368 MP m−2 day−1 for the anaesthetic room. Across both rooms and at all sampling points, an increase in levels with a decrease in MP size was observed. Identified particles consisted of mainly fragment shaped MPs (78 %) with polyethylene terephthalate (37 %), polypropylene (25 %), polyethylene (7 %) and nylon (13 %) representing the most abundant polymer types. MPs were not detected in the theatre during non-working hours. The results provide novel information on defining polymer levels and types, in a room environment where the use of single plastics has been regarded as beneficial to practice. These results can inform cellular toxicity studies, investigating the consequences of human MP exposure as well as represent a potentially novel route of exposure for humans for this emerging contaminant of concern, via surgery.

Robust surgical scheduling for nonoperating room anesthesia (NORA) under surgical duration uncertainty

AbstractNonoperating room anesthesia (NORA) refers to the practice and administration of anesthesia or sedation outside the operating room (OR), which has been increasingly implemented in practice. The novelty of NORA is to separate the anesthesia preoperative stage from an OR for the sake of saving OR time and improving its efficiency. In this article, we study the scheduling problem for NORA considering both anesthetic rooms (ARs) and operating rooms (ORs) based on ambiguous information about surgical durations. Our goal is to devise a robust and efficient scheduling mechanism for NORA. To address this problem, we develop a two‐stage mixed‐integer Robust Optimization (RO) model that minimizes the total costs, including the sum of operating costs of opened ORs and ARs, delay cost of surgeries, and overtime cost of ORs. Decisions include the number of ARs and ORs to open, the allocation of patients to ARs and ORs, the sequence of surgeries, and the planned starting time for each surgery. Accordingly, a heuristic algorithm, so‐called column‐and‐constraint generation (C&amp;CG), is developed that renders a desirable performance. Some salient properties of the problem are also discussed. In addition, by leveraging practical data in conjunction with data reported in the extant research, the computational efficacy of the proposed algorithm is verified under various sets of parameters. Our numerical experiments reveal that (1) the implementation of NORA can reduce the OR overtime cost and the waiting time of patients; (2) our proposed Robust Optimization (RO) model possesses stronger robustness and computational efficiency than the distributionally robust model (DRO); and (3) while considering surgical duration uncertainty, the developed scheduling approach outperforms the corresponding deterministic setting in terms of decreasing the total cost and alleviating the surgery delay. Generally, the proposed approach is more adaptive to take the advantage of the surgical duration uncertainty to enhance its efficacy.

Effect of self-driving of pediatric patients undergoing elective surgery to the operating room in reducing preoperative anxiety and pain and boost parental satisfaction

Background: Preoperative anxiety in children is highly prevalent, associated with negative outcomes, and has the potential to alter the dynamics of a surgical operation. If preoperative anxiety is mismanaged, it can result in postponed or canceled essential procedures. Objective: The study aimed to investigate whether self-driving of children to an operating room could relieve their preoperative anxiety and pain, in addition to assessing parental satisfaction. Methods: A prospective, two-armed quasi-experimental study was designed with three measurement time points, including 60 children (4–10 years) from both genders who had undergone elective surgeries and who were randomly allocated to the study group (n = 30) and control group (n = 30). Both groups received standard information provided by the nursing staff, and the study group only used self-driving to the operating room. The primary outcome was change in the children preoperative anxiety levels, as measured by the modified Yale Preoperative Anxiety Scale (m-YPAS) and the measurement of the physiological variables both in ward and when the children approached the anesthesia room. Pain was assessed by the Faces Pain Scale-Revised (FPS-R). A secondary outcome was parent satisfaction.

Sustainability beyond the anaesthetic room — implementing innovative methodology for simulation training

Background: In a rapidly evolving landscape of medical practice, sustainability should extend beyond the Anaesthetic room. Delivery of medical education should adopt a model that is reproducible1 through innovative means to disseminate information. To accommodate this and promote learning, we have combined use of games-based simulation and constructivism learning theory to create a novel ‘Adaptive Simulation’.